Use of a peptide

ABSTRACT

The invention employs GLP-1 (7-37), GLP-1(7-36)amide, and certain related compounds in combination with an oral hypoglycaemic agent for treating diabetes mellitus.

CROSS REFERENCE TO RELATED APPLICATIONS:

This application is a continuation of U.S. application Ser. No.09/754,723 filed on Jan. 4, 2001, which is a continuation of Ser. No.08/842,121 filed on Apr. 23, 1997, which is a continuation of Ser. No.08/295,913 filed on Oct. 13, 1994, that issued as U.S. Pat. No.5,631,224 on Oct. 28, 1998 and reissued as reissue patent RE 37,302 onJul. 31, 2001, which is a national application under 35 U.S.C. 371 ofPCT/DK93/00099 filed on Mar. 18, 1993, which claims priority to Danishapplication 363/92 filed Mar. 19, 1992, the contents of which are fullyincorporated herein by reference.

FIELD OF THE INVENTION

The present invention relates to the use of GLP-1(7-37),GLP-1(7-36)amide, or certain related compounds for the preparation of amedicament for use in the treatment of diabetes in a regimen whichadditionally comprises treatment with an oral hypoglycaemic agent. Theinvention also relates to a method of treating diabetes by using saidmedicament.

BACKGROUND OF THE INVENTION

Diabetes is characterized by an impaired glucose metabolism manifestingitself among other things by an elevated blood glucose level in thediabetic patients. Underlying defects lead to a classification ofdiabetes into two major groups: type 1 diabetes, or insulin demandingdiabetes mellitus (IDDM), which arises when patients lack β-cellsproducing insulin in their pancreatic glands, and type 2 diabetes, ornon-insulin dependent diabetes mellitus (NIDDM), which occurs inpatients with an impaired i-cell function besides a range of otherabnormalities.

Type 1 diabetic patients are currently treated with insulin, while themajority of type 2 diabetic patients are treated either with agents thatstimulate β-cell function or with agents that enhance the tissuesensitivity of the patients towards insulin.

Among the agents applied for stimulation of the β-cell function, thoseacting on the ATP-dependent potassium channel of β-cells are most widelyused in current therapy. The so-called sulfonylureas such astolbutamide, glibenclamide, glipizide, and gliclazide are usedextensively and other agents such as AG-EE 623 ZW also acting at thismolecular site are under development (AG-EE 623 ZW is a company code for(S)-(+)-2-ethoxy-4-(2-[[3-methyl-1-[2-(1-piperidinyl)phenyl]butyl]-amino]-2-oxoethyl]benzoicacid, a compound described in European patent publication No. 147,850(to Dr. Karl Thomae GmbH)). Among the agents applied to enhance tissuesensitivity towards insulin metformin is a representative example.

Even though sulfonylureas are widely used in the treatment of NIDDM thistherapy is, in most instances, not satisfactory: In a large number ofNIDDM patients sulfonylureas do not suffice to normalize blood sugarlevels and the patients are, therefore, at high risk for acquiringdiabetic complications. Also, many patients gradually lose the abilityto respond to treatment with sulfonylureas and are thus gradually forcedinto insulin treatment. This shift of patients from oral hypoglycaemicagents to insulin therapy is usually ascribed to exhaustion of theβ-cells in NIDDM patients.

Over the years, numerous attempts have therefore been made to providenovel agents which stimulate β-cell function in order to offer the NIDDMpatients an improved treatment. Recently, a series of peptides derivedfrom glucagon-like peptide-1 have been considered as insulinotropicagents for therapeutic use.

Glucagon-like peptide-1, also referred to as GLP-1, is a peptidesequence found in the C-terminal portion of mammalian proglucagon. Priorto 1985, no definite biological activity of GLP-1 had been reported.However, in 1985 it was demonstrated that the amide of a fragment ofGLP-1, namely GLP-1(1-36)amide, stimulates insulin release from isolatedprecultured rat pancreatic islets in the presence of glucose in adose-dependent manner (Schmidt, W. E. et al. Diabetologia 28 (1985)704-7). This finding suggests that GLP-1(1-36)amide and related peptidesmight be useful in the treatment of type 2 diabetes. Due to itssubstantially closer sequence homology to glucagon and glucosedependentinsulinotropic peptide, also referred to as GIP, Schmidt et al.suggested that an even stronger glucagon- and/or GIP-like biologicalactivity could be expected with GLP-1(7-36) than with the intactpeptide. In recent years, particular interest has focused on the GLP-1fragments GLP-1(7-37) and GLP-1(7-36)amide and analogues and functionalderivatives thereof. The designation GLP-1(1-36) indicates that thepeptide fragment in question comprises the amino acid residues from (andincluding) number 1 to (and including) number 36 when counted from theN-terminal end of the parent peptide, GLP-1. Similarly, the designationGLP-1(7-37) designates that the fragment in question comprises the aminoacid residues from (and including) number 7 to (and including) number 37when counted from the N-terminal end of the parent peptide, GLP-1. Theamino acid sequence of GLP-1(7-36)amide and of GLP-1(7-37) is given informula I:His-Ala-Glu-Gly-Thr-Phe-Thr-Ser-Asp-Val-Ser-Ser-Tyr-Leu-Glu-Gly-Gln-Ala-Ala-Lys-Glu-Phe-Ile-Ala-Trp-Leu-Val-Lys-Gly-Arg-X  (I)which shows GLP-1(7-36)amide when X is NH₂ and GLP-1(7-37) when X isGly-OH.

That GLP-1(7-36)amide is indeed an insulinotropic agent in man has beendemonstrated by Kreymann, B. et al. who infused this peptide intohealthy volunteers and observed a significant rise in plasma insulin(Lancet 2 (1987) 1300-304).

The insulinotropic action of GLP-1(7-37) in diabetic as well as innondiabetic subjects has been demonstrated by Nathan, D. M. et al.Diabetes Care 15 (1992) 270-76.

International Patent Application No. WO 87/06941 (to The GeneralHospital Corporation) relates to a peptide fragment which comprisesGLP-1(7-37) and functional derivatives thereof and to its use as aninsulinotropic agent.

International Patent Application No. 90/11296 (to The General HospitalCorporation) relates to a peptide fragment which comprises GLP-1(7-36)and functional derivatives thereof and has an insulinotropic activitywhich exceeds the insulinotropic activity of GLP-1(1-36) or GLP-1 (1-37)and to its use as an insulinotropic agent.

International Patent Application No. 91/11457 (to Buckley et al.)relates to effective analogs of the active GLP-1 peptides 7-34, 7-35,7-36, and 7-37.

The effect of GLP-1(7-37) in combination with glibenclamide on insulinsecretion from rat pancreatic islets was studied in vitro by Parker, J.C. et al. (Diabetes 40 (suppl. 1) (1991) 237 A). Only an additive effectof the two agents was observed.

However, to the best of the knowledge of the present inventors thesurprising synergistic effect in vivo achieved by the combined use of anoral hypoglycaemic agent and a fragment of GLP-1 or an analogue or afunctional derivative thereof has not previously been disclosed.

SUMMARY OF THE INVENTION

The present invention relates to the surprising finding that when GLP-1related peptides are administered in combination with oral hypoglycaemicagents in general and with sulfonylureas in particular for treatment oftype 2 diabetes, a synergistic effect is observed. This surprisingobservation has been made even in type 2 diabetic patients who fail torespond when sulfonylureas are administered alone.

Thus, in its broadest aspect the present invention relates to the use ofGLP-1(7-37), GLP-1(7-36)amide, or a pharmaceutically acceptable peptidecontaining a fragment of the GLP-1(7-37) sequence, or an analogue or afunctional derivative of such a peptide for the preparation of amedicament for use in the treatment of type 2 diabetes in a regimenwhich additionally comprises treatment with an oral hypoglycaemic agentand to a method of treating type 2 diabetes which method comprisesadministering an effective amount of GLP-1(7-37), GLP-1(7-36)amide, or apharmaceutically acceptable peptide containing a fragment of theGLP-1(7-37) sequence, or an analogue or a functional derivative of sucha peptide to a patient in a regimen which additionally comprisestreatment with an oral hypoglycaemic agent.

In a first preferred embodiment, the present invention relates to theuse of GLP-1(7-36)amide for the preparation of a medicament for use inthe treatment of type 2 diabetes in a regimen which additionallycomprises treatment with an oral hypoglycaemic agent.

In a further preferred embodiment, the present invention relates to theuse of GLP-1(7-37) for the preparation of a medicament for use in thetreatment of type 2 diabetes in a regimen which additionally comprisestreatment with an oral hypoglycaemic agent.

In a further preferred embodiment, the present invention relates to theuse of an analogue of GLP-1(7-37) for the preparation of a medicamentfor use in the treatment of type 2 diabetes in a regimen whichadditionally comprises treatment with an oral hypoglycaemic agent.

In a further preferred embodiment, the present invention relates to theuse of a functional derivative of GLP-1(7-37) for the preparation of amedicament for use in the treatment of type 2 diabetes in a regimenwhich additionally comprises treatment with an oral hypoglycaemic agent.

In a further preferred embodiment, the present invention relates to theuse of GLP-1(7-37) or a fragment thereof or an analogue or a functionalderivative of any of these including GLP-1(7-36)amide for thepreparation of a medicament for use in the treatment of type 2 diabetesin a regimen which additionally comprises treatment with tolbutamide.

In a further preferred embodiment, the present invention relates to theuse of GLP-1(7-37) or a fragment thereof or an analogue or a functionalderivative of any of these including GLP-1(7-36)amide for thepreparation of a medicament for use in the treatment of type 2 diabetesin a regimen which additionally comprises treatment with glibenclamide.

In a further preferred embodiment, the present invention relates to theuse of GLP-1(7-37) or a fragment thereof or an analogue or a functionalderivative of any of these including GLP-1(7-36)amide for thepreparation of a medicament for use in the treatment of type 2 diabetesin a regimen which additionally comprises treatment with glipizide.

In a further preferred embodiment, the present invention relates to theuse of GLP-1(7-37) or a fragment thereof or an analogue or a functionalderivative of any of these including GLP-1(7-36)amide for thepreparation of a medicament for use in the treatment of type 2 diabetesin a regimen which additionally comprises treatment with gliclazide.

In a further preferred embodiment, the present invention relates to theuse of GLP-1(7-37) or a fragment thereof or an analogue or a functionalderivative of any of these including GLP-1(7-36)amide for thepreparation of a medicament for use in the treatment of type 2 diabetesin a regimen which additionally comprises treatment with a biguanide.

In a further preferred embodiment, the present invention relates to theuse of GLP-1(7-37) or a fragment thereof or an analogue or a functionalderivative of any of these including GLP-1(7-36)amide for thepreparation of a medicament for use in the treatment of type 2 diabetesin a regimen which additionally comprises treatment with metformin.

In a further preferred embodiment, the present invention relates to theuse of GLP-1(7-37) or a fragment thereof or an analogue or a functionalderivative of any of these including GLP-1(7-36)amide for thepreparation of a medicament for use in the treatment of type 2 diabetesin a regimen which additionally comprises treatment with(S)-(+)-2-ethoxy-4-[2-[[3-methyl-1-[2-(1-piperidinyl)phenyl]butyl]amino]-2-oxoethyl]benzoicacid.

In this specification, analogues of GLP-1(7-37) or of GLP-1(7-36)amide,respectively, means peptides which differ from GLP-1(7-37) or fromGLP-1(7-36)amide, respectively, in that at least one of the amino acidresidues of GLP-1(7-37) or of GLP-1(7-36)amide, respectively,independently has been exchanged by another amino acid residue,preferably one which can be coded for by the genetic code. Thedefinition also comprises the case when amino acid residues are added ator deleted from the N-terminal and/or the C-terminal end of the peptide.Preferably, the total number of such additions, deletions and exchangesdoes not exceed five, more preferred it does not exceed three.

DETAILED DESCRIPTION OF THE INVENTION

As mentioned above, patients treated with sulfonylureas gradually failto respond to sulfonylurea treatment. It is generally accepted amongthose skilled in the art that this failure is due to exhaustion ofβ-cells which, accordingly, are unable to excrete insulin in response toglucose stimulation. Also, it is generally accepted that the efficacy ofsulfonylureas is limited by the capacity of β-cells to produce andexcrete insulin. Accordingly, one would not expect any additionaltherapeutic advantage by treating NIDDM patients with sulfonylureas andother agents stimulating β-cell function as well.

Our finding that NIDDM patients may advantageously be treated with GLP-1related peptides in combination with sulfonylureas or other oralhypoglycaemic agents is therefore, indeed, surprising. In fact, we havefound that concomitant treatment with oral hypoglycaemic agents andGLP-1 related peptides results in a synergistic response by the NIDDMpatients: treatment with oral hypoglycaemic agents and GLP-1 relatedpeptides gives rise to a metabolic response greater than the sum of theresponses of either agents when applied alone. Even in cases ofsulfonylurea failures, the oral agents have been found to significantlyenhance efficacy of GLP-1 related peptides.

Combined treatment with GLP-1 related peptides and oral hypoglycaemicagents is thus novel, therapeutically useful, and surprising.Unforeseen, therapeutic advantages can be gained by treating the NIDDMpatients with both types of drugs.

Among the GLP-1 related peptides that can thus be used in the treatmentof type 2 diabetes GLP-1(7-37) and GLP-1(7-36)amide are particularlyadvantageous, as they are identical to the naturally occurring hormones.Shorter peptides comprising part of the GLP-1(7-37) sequence oranalogues of such shorter peptides or analogues of GLP-1(7-37) itself orfunctional derivatives of any of these can also be used to advantage,since pharmacodynamic and pharmacokinetic properties can be changedaccording to patients' demand by modifying the GLP-1 related fragment.

The GLP-1 related peptides can be administered by methods currentlyavailable according to the invention for administration of peptides.Nasal application is particularly advantageous from a patient compliencepoint of view. Details in this respect can be found in our copendingDanish patent application No. DK 0364/92 relating to nasaladministration of medicaments comprising GLP-1 related peptides whichwas filed simultaneously with the present application. The contents ofsaid application is hereby incorporated in its entirety by reference.Administration by injection or infusion will be preferred in instanceswhere a specific protracted plasma profile of the active peptide isrequired, and oral administration is preferred in instances where extentand kinetics of absorption is not a critical issue.

The oral hypoglycaemic agent used according to the invention can be anyoral agent exhibiting a glucose lowering effect. Among these agents,those acting on the ATP-dependent potassium channel of the β-cells arepreferred such as glibenclamide, glipizide, gliclazide and AG-EE 623 ZW.The peptides according to the invention may also advantageously beapplied in combination with other oral agents such as metformin andrelated compounds or glucosidase inhibitors as, for example, acarbose.

The features disclosed in the present description, examples and claimsmay, both separately and in any combination thereof, be material forrealizing this invention in diverse forms thereof. The invention isfurther illustrated by the following examples which are not to beconstrued as limiting, but merely as an illustration of some preferredfeatures of the invention.

EXAMPLE 1

Synergistic Effect of GLP-1(7-36)amide and Glibenclamide in NIDDMPatients.

Assays

Blood samples were collected in plastic tubes containing EDTA (0.048 ml,0.34 M) and Trasylol® (1000 IU Kallikrein inhibitor, obtained fromBayer, West Germany) and immediately placed on ice. The samples werecentrifuged at 4° C. and the plasma was stored at −20° C. Blood glucosewas measured by a glucose oxidase method according to A. S. Hugget andD. A. Nixon, Lancet 2 (1957) 368-370. Plasma C-peptide concentrationswere determined by radioimmunoassay (RIA) using a commercially availablekit (Novo Research Institute, Denmark). Plasma glucagon concentrationswere measured by RIA using antibody 30K as described by G. R. Faloonaand R. H. Unger in B. M. Jaffe and Behrman, eds. Methods of HormoneRadioimmunoassay, Academic Press, New York (1974) 317-330.

For further experimental details (e.g. on calculation of isoglycaemicmeal-related insulin response, IMIR), reference is made to M. Gutniak,C. Orskov, J. J. Holst, B. Ahren and S. efendic, The New England Journalof Medicine 326 (29) (1992) 1316-1322, where a different experimentperformed under similar conditions is described.

Methods

On four different days the effect of either injecting glibenclamide, 1mg i.v., or infusing GLP-1(7-36)amide at a rate of 0.75 pmol perkilogram of body weight per minute or a combination thereof was studiedin the same group of 6 insulin treated obese NIDDM patients (Body MassIndex: 30.1±2.4 kg/m²) and compared to administration of saline ascontrol. Ordinary administration of insulin was stopped 24 hours beforethe administration of the test compounds or of the saline started andall subjects were fasted overnight. A Biostator (Miles, DiagnosticDivision, Elkhart, Ind.) was used for insulin administration in thisperiod in order to normalize blood glucose levels before theadministration of the test compounds was initiated and also to keep anormal postprandial blood glucose pattern 180 minutes following theingestion of a standard test meal comprising boiled potatoes, boiledbeef, cooked carrots, a glass of milk containing 0.5% butterfat, and aslice of bread baked from a mixture of wheat and rye flours. In thismeal, 28, 26, and 46% of the energy comes from protein, fat andcarbohydrates, respectively. Administration of the test compounds wasperformed (glibenclamide, saline) or initiated (GLP-1(7-36)amide,respectively, 30 minutes after normoglycaemia was achieved. The infusionof (GLP-1(7-36)amide was continued for 210 minutes. After 30 minutes(time zero), the subjects were given the test meal which was consumedwithin 15 minutes. Blood samples were obtained at −30, 0, 15, 30, 90,120, 150 and 180 minutes.

Results

After the ingestion of the meal, meal-related C-peptide response,glucagon response and isoglycaemic meal-related insulin requirement(IMIR) was measured. The results are summerized in Table 1. TABLE 1C-peptide response Glucagon (pg/ml/210 response min) (pg/ml/210 min)IMIR (U) Control (saline) 7.4 ± 3.6  269345 ± 6299  17.4 ± 2.8 GLP-1(7-36)amide 25 ± 9.8 10451 ± 5126  6.3 ± 2.0 glibenclamide 105 ±53.9 *) 8.3 ± 1.0 GLP-1(7-36)amide + 184 ± 55.1 2526 ± 4873 2.7 ± 0.7glibenclamide*) glibenclamide had no significant influence on glucagon release.

As indicated in the table, both GLP-1(7-36)amide and glibenclamidesignificantly increased meal-related C-peptide response (p<0.02) andwhen administered in combination exerted a clear synergistic effect.GLP-1(7-36)amide suppressed the glucagon response (p<0.0l) whileglibenclamide had no significant effect. However, in combination withGLP-1(7-36)amide the glucagon response was almost abolished. Finally,both glibenclamide and GLP-1(7-36)amide lowered IMIR and in combinationIMIR was as low as 2.7±0.7.

In summary, this experiment demonstrates a strong synergistic effect ofa combination of GLP-1(7-36)amide and glibenclamide.

EXAMPLE 2 Synergistic Effect of GLP-1(7-36)amide and Glibenclamide inNIDDM Patients With Secondary Failure to Sulfonylurea Treatment.

Methods.

Eight patients with NIDDM and secondary failure to sulfonylureatreatment participated in the study (age 57.6±2.7 years, body mass index28.7±1.5 kg/m², diabetes duration 7.6±1.2 years, HbA_(1C) 5.8±0.5). Thediabetic patients fulfilled the criteria for NIDDM and IDDM according tothe USA National Diabetes Data Group. None of the patients had impairedrenal function, automatic neuropathy, or proliferative retinopathy, andall had normal liver function. They were instructed to eat a standarddiet for diabetic patients at least 2 weeks before and during the study.The patients treated with sulfonylureas stopped their medication oneweek before the experiments. Those who were treated with insulin wereinstructed to stop the injections of NPH insulin 24 hours before thestudies. Blood glucose concentrations were controlled with subcutaneousinjections of regular insulin.

All the subjects were studied after an overnight fast. At 07.30 h on themorning of each study, three cannulas were inserted. One cannula wasplaced in an antecubital vein and was used to sample bloodintermittently for hormone assays. It was flushed with saline after eachsampling. A second cannula inserted retro-gradely in a dorsal hand veinwas used for continuous monitoring of blood glucose concentrations. Thevenous blood was arterialized by heating the forearm and hand in athermoregulated sleeve (Kanthal Medical Heating AB, Stockholm, Sweden)at 45° C. The third cannula was inserted in the contralateralantecubital vein and was used for all infusions. From approximately08.00 hours, the patients were connected to a Biostator in order tonormalize their blood glucose concentrations. The algorithm of theBiostator was adjusted in order to normalize basal blood glucose levels.The target for blood glucose concentrations was 4-5 mmol/L. When thetarget was reached, the Biostator algorithm was changed to monitoringand the feedback insulin infusion was stopped. The experiments werestarted 30 minutes after normoglycemia was achieved, approximately 90minutes after connection to the Biostator. An infusion of saline or 0.75pmol/kg/min of GLP-1(7-36)amide (Peninsula Laboratories, St. Helens,Merseyside, England) then was started and continued for 210 minutes. Inglibenclamide experiments an i.v. injection of 1 mg glibenclamide(Hoechst AG, Germany) was given at the same time point. These fourstudies were performed in a random order with 2-4 weeks elapsed betweenthe experiments. At time 0 the subjects were given a standard lunch, asdescribed in Example 1 which they ate within 15 minutes while sitting inbed. Blood samples were taken at FV, −60, −30, −15, 0, 15, 30, 90, 120,150, and 180 minutes. Blood glucose was measured continuously.

Results.

In the basal state, the effect on blood glucose and C-peptide levels wasmonitored 45 minutes after administration of GLP-1(7-36)amide,glibenclamide or a combination thereof had started. The results aresummarized in Table 2. TABLE 2 Blood glucose C-peptide mmol/l pmol/lControl (saline) 6.0 ± 0.3  0.53 ± 0.06 GLP-1(7-36)amide 5.1 ± 0.4 0.63± 0.1 glibenclamide 6.0 ± 0.3  0.56 ± 0.007 GLP-1(7-36)amide + 4.5 ± 0.10.72 ± 0.1 glibenclamide

These results clearly demonstrates the synergistic effect of the twocompounds as glibenclamide had no significant effect on its own whilethe effect of the combination of GLP-1(7-36)amide and glibenclamide,clearely, exeeded that of GLP-1(7-36)amide alone.

After the ingestion of the meal, the insulinogenic indices (integratedinsulin/integrated glucose response) were calculated, again highlightingthe synergistic effect of the two compounds, a shown in Table 3. TABLE 3Insulinogenic index Control (saline)  1.6 ± 0.6 GLP-1(7-36)amide 21.0 ±7.2, glibenclamide 10.6 ± 2.8, GLP-1(7-36)amide + glibenclamide 37.5 ±9   

1. A method for treating type 2 diabetes, said method comprisingadministering to a patient in need of said treatment i) an effectiveamount of metformin via oral administration and ii) an effective amountof an insulinotropic GLP-1 related peptide via injection or infusion,where said insulinotropic GLP-1 related peptide is selected from thegroup consisting of GLP-1 (7-37), GLP-1 (7-36) amide, an analogue ofGLP-1 (7-37) and an analogue of GLP-1 (7-36) amide.
 2. The method ofclaim 1, wherein said insulinotropic GLP-1 related peptide is GLP-1(7-36) amide.
 3. The method of claim 1, wherein said insulinotropicGLP-1 related peptide is an analogue of GLP-1 (7-37).
 4. The method ofclaim 3, wherein said analogue of GLP-1 {7-37) has one amino acid ofGLP-1 (7-37) exchanged by another amino acid.
 5. A method for treatingtype 2 diabetes, said method comprising administering to a patient inneed of said treatment i) an effective amount of metformin via oraladministration and ii) an effective amount of an insulinotropic GLP-1related peptide via injection or infusion, where said insulinotroplcGLP-1 related peptide is selected from the group consisting of afunctional derivative of GLP-1 (7-37), a functional derivative of GLP-1(7-36) amide, a functional derivative of an analogue of GLP-1(7-37) anda functional derivative of an analogue of GLP-1 (7-36) amide.
 6. Themethod of claim 5, wherein said insulinotropic GLP-1 related peptide isa functional derivative of an analogue of GLP-1 (7-37).
 7. The method ofclaim 6, wherein said analogue of GLP-1 (7-37) has one amino acid ofGLP-1(7-37) exchanged by another amino acid.
 8. A method for treatingtype 2 diabetes, said method comprising administering to a patient inneed of said treatment an amount of metformin and an amount of aninsulinotropic peptide effective to treat said type 2 diabetes whereinthe insulinotropic peptide is an insulinotropic GLP-1 related peptideselected from the group consisting of GLP-1 (7-37), GLP-1 (7-36) amide,an analogue of GLP-1 (7-37), an_analogue of GLP-1 (7-36) amide, afunctional derivative of GLP-1 (7-37), a functional derivative of GLP-1(7-36) amide, a functional derivative of an analogue of GLP-1 (7-37) anda functional derivative of an analogue of GLP-1 (7-36) amide.
 9. Themethod of claim 8, wherein the insulinotropic peptide is aninsulinotropic GLP-1 related peptide selected from the group consistingof GLP-1 (7-37), GLP-1 (7-36) amide, [[or]] an analogue of GLP-1 (7-37)and an analogue of GLP-1 (7-36) amide.
 10. The method of claim 8,wherein the insulinotropic peptide is an insulinotropic GLP-1 relatedpeptide selected from the group consisting of a functional derivative ofGLP-1 (7-37), GLP-1 (7-36) amide, a functional derivative of an analogueof GLP-1 (7-37) and a functional derivative of an analogue of GLP-1(7-36) amide.
 11. The method of claim 9, wherein said insulinotropicGLP-1 related peptide is GLP-1 (7-36) amide.
 12. The method of claim 9,wherein said insulinotropic GLP-1 related peptide is an analogue ofGLP-1 (7-37).
 13. The method of claim 12, wherein said analogue of GLP-1(7-37) has one amino acid of GLP-1 (7-37) exchanged by another aminoacid.
 14. The method of claim 10, wherein said insulinotropic GLP-1related peptide is a functional derivative of an analogue of GLP-1(7-37).
 15. The method of claim 14, wherein said analogue of GLP-1(7-37} has one amino acid of GLP-1(7-37) exchanged by another aminoacid.
 16. The method of claim 8, wherein the insulinotropic peptide isadministered to the subject via injection or infusion.
 17. The method ofclaim 8,.wherein the metformin is administered to the subject orally.18. The method of claim 8, wherein said metformin is administered to thesubject orally and said insulinotropic peptide is administered to thesubject via injection or infusion.